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MASA Opt Out Form

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  2. PLEASE READ:

    To opt out of MASA, please provide the following information so that we can verify your account status. 

    Once the form has been completed and processed, you and your household will be removed from MASA and the charge for MASA will be removed from future utility bills. 

    Please note that you MUST opt out by the 15th of the current month in order for service to end at the end of the current month. 

    For example, if you opt out of MASA on January 14th, then your MASA service will end on January 31st and the charge will be removed from the bill you receive in February and onward. However, the charge would still appear on your bill for January. 

    If you opt out after the 15th of January, then your service would end February 28th and you would still see the charge on your bills for January and for February.

  6. Resident Account Information

    All information provided must match the information the Town has on file for your account. This information can be found on your most recent utility bill. 

  12. Account Number

    Please enter your account number below. Your account number is 13 digits split into three sections separated by hyphens ( - ).  Please enter numbers only.

  14. Enter first 3 digits

  15. Enter next 7 digits

  16. Enter last 3 digits

  22. Contact Information
  30. Confirmation of Service Optout*

    By marking the check box below, I confirm that I am an authorized account holder for this account and that I am voluntarily choosing to opt out of the medical transportation service MASA that is offered by the Town and that is charged as part of my monthly utility billing. 

    I also confirm that I understand that by opting out that my service with MASA will end based on the following schedule:

    • If opting out ON or BEFORE the 15th of the current month, then my service with MASA will end at the end of this current month. 
    • If opting out AFTER the 15th of the current month, then my service will continue for the rest of the current month and the following month before ending.
    33. Leave This Blank:

  35. This field is not part of the form submission.